Educational Supplement

Educational objectives:

Upon completion of this course, participants should be able to achieve the following:

• Understand the history of the development of CEREC technology
• Evaluate the process of purchasing CEREC technology
• Discuss the CEREC process from image to seating the restoration
• Discuss the advantages of single-visit dentistry

Abstract:

CEREC Chairside technology has gone through many changes over the years. Included is a brief history of those changes, one clinician’s story using this technology and a case study using the latest in both the hardware and software components.

From the beginning, CEREC Chairside has gone through many improvements. The original CEREC 1 used a single diamond-coated wheel to grind ceramic blocks, first producing only inlays, then later onlays and veneers. In 1994, CEREC 2 was unveiled. This version uses a cylindrical diamond bur in addition to a wheel to add partial and full crowns to the types of restorations CEREC could fabricate. Both CEREC 1 and CEREC 2 machines were packaged together, meaning the acquisition and milling components were part of one unit.

In 2000, CEREC 3 was introduced. It marked the splitting of the acquisition and milling components into separate units. It was also the first CEREC fabricator to use two diamond burs, one cylindrical and one cone-shaped, to create the ceramic restorations.

In November 2001, I decided to purchase the CEREC Chairside system. Since it was a rather expensive purchase, I wanted to be as sure as possible in making my decision. I took the number of posterior ceramic restorations I had performed the previous 12 months. I then calculated 90 percent of that number and multiplied it by my current lab charge for those restorations. The numbers “worked,” meaning the money that I was saving from the lab costs would more than cover my monthly payments for the CEREC system. With the help of my front-desk person, who had once worked in a dental office that had a CEREC 1 system, we were able to schedule one appointment for every indirect restoration that had to be done instead of two. Finishing the procedure in one appointment eliminated the necessity for the patient to wear a provisional restoration and the possibility of the provisional coming off before the seat appointment. Because the patient did not have to return to have the restoration seated, this allowed us more time for additional production.

Another important advantage was that I now had total control of the restorations, rather than relying on a lab to produce them for me. This responsibility, I believe, increased my clinical abilities. In the September 2006 issue of JADA, Drs. Trost, Stines and Burt published a detailed article concerning making decisions about incorporating a Chairside CAD/CAM system.2

In 2001, the software was still two dimensional. When diagramming a restoration, one looked at different windows on the computer screen and “visualized” whether the finish line was on tooth structure, placed a dot on a broken line and drew another line to establish a contact. The user then looked at two windows to see if he had it right. Needless to say, the software proved challenging.

The software changed dramatically in early 2003 when it became three-dimensional. This made the designing of the restorations much easier and intuitive, giving users a real advantage. Since 2005, other improvements have been made to the software that allow users to add or subtract portions of the restorations. Another improvement includes a tool (antagonist) that settles a restoration. Also, a step cylinder bur was added that enables more precise milling without the over-milling of the 1.6mm cylinder bur or the frequent breakage of the 1mm bur.

With these new changes, the Chairside CEREC will prove to be easier and faster to use, with the ability to produce a more exact restoration.

The software’s main feature improvement is a new method for generating inlay and onlay proposals. These proposals had not been updated for several years. Sirona has developed the Biogeneric program; a sophisticated and totally new way of restoring missing tooth structure. The software analyzes the remaining tooth structure and searches its internal information for the best fit. This is then modified to the situation at hand in a way that does not distort the morphology of the new tooth in an abnormal way. Drs. Mehl and Blanz described the Biogeneric tooth model in Computerized Dentistry.3 This method uses a mathematical analysis of a large number of occlusal surfaces from a tooth library. The tooth model is then calculated using appropriate parameters. Dr. Stefan Hehn, during his presentation at the CEREC 20th Anniversary Celebration, said that the future may bring us to a point where someone takes a picture of the prepared tooth, clicks the mill button and the ideal tooth restoration is created. Sirona has brought the future much closer to the present with the Biogeneric software.

The software is now divided into two modes – CEREC 3D Software and Master Mode. The CEREC 3D software will allow new CEREC users to create restorations easier and faster by reducing the learning curve of the current software. The design process has been greatly simplified. The CEREC 3D software will be for single-posterior restorations only. All other restorations and quadrants will be able to be done in Master Mode.

With the release of the CEREC MC XL milling unit, the CEREC user will have the capability to mill a restoration 60 percent faster with a smoother surface.

What follows is a case study using the Biogeneric portion of the CEREC 3D software milled with the CEREC MC XL.

Case Study
Patient Information and Diagnosis

A 63-year-old woman presented with cold and biting sensitivity on tooth #13. The tooth had a large three- surface amalgam filling and a visible fracture. Using visual clinical examination, radiographs and Tooth Slooth II (Professional Results, Inc.), the diagnosis of recurrent decay and cracked buccal cusp was made.

After discussing the findings with the patient, the decision was made to restore the tooth with a MODB partial crown/onlay utilizing the CEREC 3D Chairside CAD/CAM system. The patient was pleased to have the tooth restored in one appointment because of her busy work schedule. We were confident in the method of restoring the tooth based on Dr. Dennis Fasbinder’s review on different studies of clinical performance of CEREC Chairside CAD/CAM restorations.4

Treatment Procedures
Preparation

Patient was anesthetized using topical anesthetic gel, one-half carpule of 4% Citanest Plain (Astra Zeneca) and one-half carpule Septocaine with 1:100,000 epinephrine (Septodont). The Isolite Dryfield Illuminator (Isolite Systems) isolation system was then placed (Fig. 1). Preparation was started using a 2mm ball diamond to reduce the occlusal aspect of the tooth. After the preparation was finished, the Isolite was removed and a bite registration was taken with Metal Bite (R-Dental Co.). The Isolite was then placed again.

Imaging and Design

After placing the Isolite, the prepared tooth was cleaned with 70% isopropyl alcohol using an UltraDent syringe (UltraDent). Preparation was air dried, then sealed with Surpass (Apex Dental Materials). Studies show there is no decrease in bond strength when applying the bonding material before powdering.5 A trough in the interproximal areas was created by use of SIROlaser (Sirona). The preparation was powdered with a titanium dioxide material, CEREC Powder (Vident) by the use of a powder Meister (Powder Meister Company).

Optical images/impressions of the preparation and bite registration were taken (Fig. 2 and Fig. 3). The powder was then removed, using 70% isopropyl alcohol. A partial crown/onlay was designed using the CEREC 3D Software (Fig. 4). After slight modification with the software’s Form Tool, the data was sent to the CEREC MC XL milling chamber where the restoration was milled from a Vita Mark II shade 3M1 block. The design and milling of the restoration took less than 10 minutes. After trying in the restoration, (Fig. 5) it was characterized using Vita Akzent stains and glaze (Vident) and a Vacumat 40 porcelain oven (Vident).

After firing, the internal aspect of the restoration was sandblasted using 27 micron aluminum-oxide abrasive powder. The restoration was then steam cleaned using a Vident Steam Cleaner (Vident). The internal aspect was prepared with Interface Ceramic Primer (Apex Dental Materials). The main advantage of this material is that it allows the ceramic to be prepared without use of hydrofluoric acid. Surpass 3 (Apex Dental Materials) was then placed and air thinned, then cured. The Isolite is placed again and the preparation is cleaned with 70% isopropyl alcohol, coated with Surpass 3, air thinned and cured. Anchor Luting Material (Apex Dental Materials) is then placed in the restoration and seated. After the material gels, excess material is removed using an explorer. Contacts are flossed and the restoration was cured 10 seconds on the occlusal and buccal surface using an UltraLume 5 (UltraDent). The Isolite was then removed and occlusion of the restoration was verified (Fig. 6). In many cases, to allow the patient the opportunity to receive this type of dentistry, we offer a patient finance program.

From Dr. Mörmann’s initial concept to the latest software and hardware advancements, CEREC Chairside CAD/CAM system allows dentists to serve patients by offering them solutions to their restorative needs in a single visit with predictable, proven results.

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Author’s Bio

Dr. Mark J Fleming is a 1978 graduate of The Ohio State University College of Dentistry. He maintains a full time practice in Sarasota, Florida. Dr. Fleming is a regular contributor to the message boards of Dentaltown and has spoken to several international dental groups. He also serves as a consultant to a variety of dental manufacturers helping in product evaluation and design. He is currently president-elect of the Academy of Computerized Dentistry of North America, which furthers the understanding and use of computerized technologies and machinable restorative materials in dentistry.

Disclosure: Dr. Fleming declares having received an honorarium from the sponsors to create this educational case study.

Bibliography
1. Mormann WH. The evolution of the CEREC system. Supplement to JADA 2006; 137:75-13.
2. Trost L, Stines S, Burt L. Making informed decisions about incorporating a CAD/CAM system into dental practice. Ibid. 325-65.
3. Mahl A, Blanzv. New procedure for fully automatic occlusal surface reconstruction by means of a Biogeneric tooth model. Int J Computerized Dentistry 2005 Jan; 8 (l): 13-25.
4. Fasbinder D J. Clinical performance of chairside CAD/CAM restorations. Ibid., 225-315.
5. Kanca III J. Private conversation 2005.

This CE activity is sponsored by an unrestricted grant from CareCredit, Isolite Systems and Sirona

Dr. Richard Rosenblatt, who practices in Lake Forest and Chicago, Illinois, discusses his experiences with CEREC dentistry and CareCredit patient financing.

The elusive single visit. Patients and doctors crave it, as it frees up valuable time on both ends. It used to be that a patient would come in for the restoration prep-work and then come in once more for the seating, but with the combination of CEREC Chairside systems and CareCredit patient financing – the second visit is becoming a thing of the past.

We have implemented both CEREC and CareCredit in our practice and haven’t looked back since. Patients love that they don’t have to get numb a second time, or have a temporary seated or have to take impressions. They appreciate that they don’t have to miss work or other obligations in order to come back for a second visit. For us, the fact that we don’t have to make temps and that we are able to open up the schedule for productive appointments instead of being bogged down with crown seats are huge advantages.

The two main factors that helped us decide to purchase a CEREC system for our practice were the potential for return-on-investment and the conveniences it allows for both me and my patients. I work in a two- doctor practice and we do a fair amount of indirect restorations. Our office averaged more than 35 single posterior units a month between the two of us. The savings in lab bill was at least $3,500 a month – pretty dramatic. The other factor that influenced our decision was the convenience of the single visit for the patient and us.

For me, CEREC and CareCredit go hand in hand. While CEREC allows me to seat a finished crown in one visit, CareCredit helps alleviate the financial burden on the patient by offering a payment plan the patient can be comfortable with.

Patient financing has been instrumental to our practice to help us provide single-visit dentistry. People come into our practice every day with broken teeth who need onlays and crowns. The problem is that they either don’t have insurance to help with the payment or cannot afford their portion of the treatment that day to have the necessary treatment done. CareCredit allows patients to get the treatment they need that very day.

When patients come in for an emergency, many do not have the cash on hand to pay for their care in full. When they need procedures done such as root canals or crowns, it can get costly. If a patient cannot afford the treatment and were to leave my practice, I might never see that patient again. CareCredit allows the patient to get that necessary work done and it’s possible for that person to become a long-term patient. We might even get a few referrals from it.

Financing for people who cannot immediately pay for their treatment is one of the many advantages CareCredit financing offers. I offer patient financing to every patient who comes into our office for treatment. We have many patients who choose to finance their care, even if they have the money to pay for the treatment. Our patients really like the 12-month interest-free option. When they realize that they have 12 months to pay for the treatment and there is no interest charged to them, why wouldn’t they choose that option? I can’t tell you how many televisions and computers I’ve purchased that I financed in the exact same way.

CareCredit gives patients so many options. Patients can pay over a determined amount of time with no interest. Or they can extend those payments out with an affordable interest rate at a monthly payment that the patient can afford. The customer service is stellar with CareCredit. The only people who are more appreciative of CareCredit than me are my patients.

Puri: Ceramic is a little bit more aggressive than gold because you need more thickness with the ceramic than you do with a gold restoration. Properly done, I think a CEREC is very conservative. I can save tooth structures that I would otherwise have to cut down just to retain a temporary or to retain the permanent crown. With CEREC, I can just replace what’s missing.

DiTolla: When you first purchased your CEREC, what was your investment in terms of time, training and money?

Agarwal: CEREC is a big investment, no question about it. But more importantly, it represents a line-item shift in your practice. In actuality, the machine didn’t cost me anything because I replaced my laboratory bill with my CEREC payment.

DiTolla: How were you able to weigh the cost versus the benefit when making the decision to purchase CEREC?

Fleming: My receptionist had added up all the ceramic restorations I had to send out. She then added up the time it takes to get the restorations back. She also added in further training. After she subtracted 10 percent from that sum, we compared what my monthly CEREC payments were going to be against my current lab fees. It came back incredibly positive. That just sealed the deal for me.

DiTolla: Is there a “litmus” test for whether or not it makes sense for a practice to get a CEREC machine? Is there a minimum number of restorations you need to be doing a month to be able to pay for it?

Puri: The way to determine if CEREC is going to work in your practice is to look at your lab bill. I’m doing 40 restorations a month at $200 a unit and that’s $8,000 in lab bill. If I do those same 40 units with CEREC, I’m still fixed at $2,000 a month. This is a capital equipment investment that you can depreciate, which saves you even more money.

DiTolla: Why are so many doctors still struggling with the decision to purchase a CEREC? Why is there so much skepticism about this technology?

Agarwal: I think the biggest roadblock for most dentists is themselves. My staff is pushing me to do things with CEREC now that I was having the lab do before. They are taking me to the next level by promoting CEREC to our patients. They are asking patients if they would like us to take care of their restorations today during their visit.

DiTolla: Is getting your staff to buy into the concept important in laying the foundation for integrating CEREC into your practice?

Agarwal: You have to have your team on board. The best advice I can give is to do “technical updates” with your team members. Every month I sit down and I’ll show them cases and techniques and introduce them to new products and current events in dentistry.

DiTolla: Who within the practice is responsible for setting the stage for success when purchasing a CEREC? How is that done?

Agarwal: It is important that every team member is on board with any technology you purchase. Your team members should be trained to understand what processes are involved and how to make treatment comfortable for your patients. The most important person in my practice has been my treatment coordinator. She is completely responsible for seeing our patients through each step of the way. She’s able to sit down with the patient and present all the different patient payment options, including using CareCredit, to make the procedure affordable.

Fleming: The bottom-line decision will be made by whoever is paying for it, which is usually the dentist. I made sure that there was a demonstration for the staff. Everyone had the opportunity to ask questions. It doesn’t matter how good you are or what the technology can do for you; if you don’t involve the people who you work with, you’re paddling upstream.

DiTolla: How easy or difficult was it to integrate CEREC in your daily routine?

Puri: For the first 10 restorations, we took an impression of the patient and my assistant would ask me what lab we were sending it to. I would tell her we are sending it to the Sirona Lab. We’d put on a temporary, send the patient home and make the restoration on the model. It is pretty easy to integrate clinically. Most people are able to pick that up fairly well.

DiTolla: Did purchasing your CEREC affect the fees that you charge the patients? If it did, how did it affect them?

Puri: We keep our fees the same whether we’re doing a CEREC restoration, a gold crown, or a PFM. It’s all the same. I wouldn’t want to switch fees on the patient midstream.

DiTolla: How has CEREC impacted the top line of your practice, increasing production and case acceptance? How do you enhance your production by using the “single visit” concept?

Puri: It’s wonderful to tell patients, “You need this crown, we can have it done today, and you have six months to pay for it.” We’ve had tremendous growth in our practice over the last few years, and CEREC and CareCredit patient financing have been a huge part of that.

Agarwal: One of the biggest difficulties in our practice is always the ability to sit down and spend time with patients. What I’ve learned is that typically, in my one-and-a-half hour block for CEREC, there’s about 20 to 30 minutes that I’m free to spend with new patients and get a better feel as to why they’re here. Then I can spend more time explaining what we can do for them. I’ve gotten comments like, “I’ve never had a dentist who sat down with me or has taken this much time with me.” I’ve seen a greater case acceptance and a greater appreciation from my patients.

DiTolla: How does having a CEREC affect patient loyalty and satisfaction? Do you receive referrals from patients who you have performed CEREC restorations on?

Puri: We’ve had a lot of patient referrals because they will have a visitor from out of town who breaks a tooth. Usually when that happens they will send them to their local dentist and ask, “Can you put a temporary on them?” Now, they’ll send them to us and ask, “Can you put a permanent crown on that patient?” and we can do it in one visit.

DiTolla: Why is it important to have more control over certain procedures?

Puri: As soon as you’re done prepping, you take a picture of the tooth and it shows up on your screen. You get to design your restoration right there. That means you have to be able to see your margins. You also have to make sure you have enough clearance in your restoration. You have that instant feedback.

DiTolla: How has using the CEREC machine impacted your ability to deliver exceptional dentistry?

Agarwal: It has completely changed the way my practice works. My practice has gone from seeing eight to 10 patients a day to about four or five a day. We’ve also increased our practice productivity and profitability. I have been able to do things I enjoy such as making restorations, staining them and making them look fantastic. Our team members are more excited about dentistry and even our patients are more excited. When our patients can get excited about dentistry, we tend to see more referrals.

DiTolla: Does the combination of patient financing and CEREC technology help when a patient breaks a tooth and wants to get it fixed quickly?

Mirzayan: Patient financing works great in any aspect of dentistry. It completely removes us from the role of being the bill collector. We are able to present the patient with all of the different financing options. The rates and the way it is structured is very amicable for the patients, particularly the ones where they don’t have to pay interest. We absorb that, but it is such an insignificant cost and with the CEREC, we are able to get the work done right then and there.

DiTolla: What has been the single biggest benefit of having a CEREC? Is it ease of use, precision, predictability, or is it the ability to control overhead?

Agarwal: In my opinion, it’s each one of those.

Puri: The ability to control my overhead.

Fleming: I love the predictability. I love what it does for the patients. The staff is enthused about it. They get to talk about it. Everyone on the staff has CEREC restorations in their mouths so they can personally speak to it.

DiTolla: If you were talking to a friend of yours who is a dentist, and he was considering purchasing a CEREC machine, what would you say to him?

Puri: Run, don’t walk. Get proper training. There are a lot of good resources out there to get trained well. Take your time with the machine.

Fleming: I would ask him, if he was considering CEREC, what led him to make this decision. I would ask how the CEREC is going to impact him, the practice and the patients. I would ask him where purchasing this system fits into his practice’s philosophy. I would tell him to make his values and purpose so clear that his work is a reminder of what he likes best about himself. I believe you have to look at your beliefs and values in order to make a proper decision to purchase a CEREC.

Agarwal: If you are looking for excitement in your practice and if you are looking to step up to cutting edge dentistry, then CEREC makes sense. It allows you to have a technology in your office many other dentists don’t have. And it allows you to provide beautiful dentistry.

Mirzayan: You can conceivably pay this machine off, take the depreciation, fix your lab overhead, and come out thousands of dollars ahead in the first year. If you wait two, three or four years then you’re going to lose out on a tremendous opportunity to take advantage of all the benefits CEREC provides.